MIAMI BEACH -- Some American soldiers are returning from Iraq with
a dormant pathogen in tow cutaneous leishmaniasis. Symptoms of the
infection can take 4-6 months to appear after a bite from an infected
sand fly, and some unknowingly infected military personnel return to
their communities before the lesions develop. This puts community
dermatologists in the position of having to treat this tropical
infection.

There is a seasonal variance to this protozoan parasitic infection
that corresponds with the activity of sand flies in the Middle East.
During the 2003-2004 season, localized cutaneous leishmaniasis was
frequently diagnosed in U.S. military personnel, with most infections
caused by Leishmania major, according to a presentation at the annual
meeting of the American Society of Tropical Medicine and Hygiene.

There have been more than 500 reported cases since January 2003
among soldiers from Operation Enduring Freedom and Operation Iraqi
Freedom, according to U.S. Army medical research data.

Experience with 300 soldiers treated at Walter Reed Army Medical
Center in Washington demonstrates that there are multiple presentations
for localized cutaneous leishmaniasis. Of the infected patients, 98%
were male, 96% were in the U.S. Army, and 91% were enlisted personnel.
Almost three-quarters (73%) were white; 16% were African American, 6%
were Hispanic, and 5% were from other ethnic groups.

"Patients with lighter skin were over-represented in our
cohort," said Naomi E. Aronson, M.D., professor of medicine and
director of the infectious diseases division, Uniformed Services
University of the Health Sciences, Bethesda, Md.

Cutaneous leishmaniasis manifests after the multiplication of the
organism in phagocytes in the skin. The mean number of skin lesions per
patient was 3, and the range was 1-47. The mean time between appearance
of a lesion and initiation of treatment was 13 weeks.

Papules often appear first, followed by ulcerative lesions. Lesions
commonly appear in pairs. Nodules are uncommon in leishmaniasis. A rare
presentation is a large psoriasiform-type plaque containing several
small lesions. "I've seen about 10 cases of this form,"
Dr. Aronson said. Facial lesions, including those on the lips or pinna of the ear, tend to be more inflammatory, Dr. Aronson commented.

Leishmaniasis lesions do not typically feature purulent drainage;
if the lesion is tender with pus, it is likely a bacterial
superinfection, Dr. Aronson explained. Both the lesions and the
resultant bacterial infection may require concurrent treatment courses.

Sand flies are attracted to bright colors, so soldiers are
sometimes bitten on exposed tattoos, she said. "A common complaint
in our clinic is 'the sand fly messed up my tattoo.'" The
cutaneous form of the disease is ultimately self-healing, although
disfiguring scars can remain. The visceral and mucosal forms of
leishmaniasis are often more serious and sometimes fatal. Educate
patients that not all treatments are 100% effective, Dr. Aronson
suggested. "It is important to give patients realistic expectations
that leishmaniasis may not be gone, but it should improve."

There are no leishmaniasis treatments that have been approved by
the Food and Drug Administration. Topical treatments include heat
therapy and cryotherapy. Some lesions will respond to treatment with
ThermoMed (Thermosurgery Technologies, Inc.) but others only partially
respond, Dr. Aronson reported. A clinical trial investigating the
technology is underway at Walter Reed Army Medical Center. Cryotherapy
with liquid nitrogen is another treatment strategy.

Standard therapy for all forms of the disease is pentavalent antimony of sodium stibogluconate (Pentostam, GlaxoSmithKline) or
meglumine antimonate (Glucantime, Aventis). The usual parenteral regimen
of sodium stibogluconate, for example, is 20 mg/kg per day for 20 days.

Pentavalent antimonials are available only through an
Investigational New Drug (IND) protocol from the Centers for Disease
Control and Prevention. Investigational agents require a lot of
paperwork--and institutional review board approval--before they are
available for use, Kenneth R. Dardick, M.D., said during a separate
presentation at the meeting. Pharmacists need to be educated about
storage requirements and nurses instructed to handle the agents as they
would a chemotherapy drug. Informed consent is required from patients.

It is possible that physicians working in a community hospital will
see only one or two cases of this rare disease. Physicians unfamiliar
with use of pentavalent antimonials should consult military and/or CDC
infectious disease experts, suggested Dr. Dardick, a family physician at
Mansfield Family Practice, Windham Hospital, Storrs, Conn.

The IND requirements "can be novel for a community
hospital," Dr. Dardick added. "But cutaneous leishmaniasis can
be successfully diagnosed and treated in a community hospital with
appropriate index of suspicion."

BY DAMIAN MCNAMARA

Miami Bureau

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